D
F-550
no actual harm; potential for more than minimal harm · isolated
Residents weren't treated with dignity or weren't allowed to make their own choices.
CMS requirement: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected Sep 23, 2022
D
F-584
no actual harm; potential for more than minimal harm · isolated
The building or rooms weren't kept safe, clean, comfortable, and homelike.
CMS requirement: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected Sep 23, 2022
G
F-600
actual harm · isolated
A failure to protect residents from abuse, neglect, or physical punishment.
CMS requirement: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected Sep 23, 2022
E
F-607
no actual harm; potential for more than minimal harm · pattern
The home's written policies to prevent abuse, neglect, and theft were missing or not followed.
CMS requirement: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected Sep 23, 2022
E
F-609
no actual harm; potential for more than minimal harm · pattern
Suspected abuse, neglect, or theft wasn't reported to authorities on time.
CMS requirement: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected Sep 23, 2022
E
F-610
no actual harm; potential for more than minimal harm · pattern
Reported abuse or neglect allegations weren't properly investigated or acted on.
CMS requirement: Respond appropriately to all alleged violations.
Corrected Sep 23, 2022
E
F-625
no actual harm; potential for more than minimal harm · pattern
Residents weren't told in writing how long their bed would be held during a hospital stay.
CMS requirement: Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected Nov 8, 2022
D
F-656
no actual harm; potential for more than minimal harm · isolated
Care plans were missing pieces — not every need a resident has was written into a measurable plan.
CMS requirement: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected Sep 23, 2022
D
F-657
no actual harm; potential for more than minimal harm · isolated
Care plans weren't finished within 7 days of assessment, or weren't built and reviewed by the right team.
CMS requirement: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected Sep 23, 2022
D
F-676
no actual harm; potential for more than minimal harm · isolated
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected Nov 8, 2022
D
F-677
no actual harm; potential for more than minimal harm · isolated
Residents who need help with daily basics — bathing, dressing, eating, hygiene — didn't get that help.
CMS requirement: Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected Sep 23, 2022
E
F-684
no actual harm; potential for more than minimal harm · pattern
Residents didn't get treatment or care the way their doctors ordered or their care goals called for.
CMS requirement: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected Sep 23, 2022
E
F-686
no actual harm; potential for more than minimal harm · pattern
Pressure ulcer (bedsore) care fell short — existing sores weren't treated properly or new ones weren't prevented.
CMS requirement: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected Sep 23, 2022
D
F-688
no actual harm; potential for more than minimal harm · isolated
Residents didn't get care to maintain mobility and range of motion.
CMS requirement: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected Sep 23, 2022
D
F-689
no actual harm; potential for more than minimal harm · isolated
Inspectors found accident hazards, or residents weren't supervised closely enough to prevent falls and injuries.
CMS requirement: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected Sep 23, 2022
D
F-697
no actual harm; potential for more than minimal harm · isolated
Pain wasn't managed safely or appropriately.
CMS requirement: Provide safe, appropriate pain management for a resident who requires such services.
Corrected Sep 23, 2022
D
F-698
no actual harm; potential for more than minimal harm · isolated
Dialysis care or coordination with dialysis providers wasn't safe or appropriate.
CMS requirement: Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected Sep 23, 2022
D
F-726
no actual harm; potential for more than minimal harm · isolated
Nurses and aides lacked the demonstrated skills to care for their residents.
CMS requirement: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected Sep 23, 2022
D
F-755
no actual harm; potential for more than minimal harm · isolated
Pharmacy services fell short — the facility didn't properly use a licensed pharmacist to manage medications.
CMS requirement: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected Sep 23, 2022
D
F-803
no actual harm; potential for more than minimal harm · isolated
Menus didn't meet residents' nutritional needs or weren't followed.
CMS requirement: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected Sep 23, 2022
D
F-812
no actual harm; potential for more than minimal harm · isolated
Problems with safe food handling — storage temperatures, kitchen sanitation, or food from unapproved sources.
CMS requirement: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected Sep 23, 2022
D
F-880
no actual harm; potential for more than minimal harm · isolated
The home didn't follow infection prevention and control rules — things like hand hygiene, isolation precautions, or tracking infections.
CMS requirement: Provide and implement an infection prevention and control program.
Corrected Sep 23, 2022
D
F-908
no actual harm; potential for more than minimal harm · isolated
Essential equipment wasn't kept in safe working order.
CMS requirement: Keep all essential equipment working safely.
Corrected Sep 23, 2022